Coverage Summary
Oxygen for Home Use
Policy Number: O-003
Products: UnitedHealthcare Medicare Advantage Plans
Approved by: UnitedHeatlhcare Medicare Benefit Interpretation Committee
Original Approval Date: 04/15/2009
Last Review Date: 02/14/2017
Related Medicare Advantage Policy Guidelines:


Home Oxygen Use To Treat Cluster Headache (CH) (NCD 240.2.2)
Home Use of Oxygen (NCD 240.2)

Home Use of Oxygen in Approved Clinical Trials
(NCD 240.2.1)
This information is being distributed to you for personal reference. The information belongs to UnitedHealthcare and
unauthorized copying, use, and distribution are prohibited. This information is intended to serve only as a general reference
resource and is not intended to address every aspect of a clinical situation. Physicians and patients should not rely on this
information in making health care decisions. Physicians and patients must exercise their independent clinical discretion and
judgment in determining care. Each benefit plan contains its own specific provisions for coverage, limitations, and exclusions
as stated in the Member’s Evidence of Coverage (EOC)/Summary of Benefits (SB). If there is a discrepancy between this
policy and the member’s EOC/SB, the member’s EOC/SB provision will govern. The information contained in this document is
believed to be current as of the date noted.
The benefit information in this Coverage Summary is based on existing national coverage policy, however, Local Coverage
Determinations (LCDs) may exist and compliance with these policies is required where applicable.
INDEX TO COVERAGE SUMMARY
I.
II.
III.
IV.
I.
COVERAGE
1. Indications and Limitations of Coverage
2. Medical Documentation, Laboratory Evidence and Covered Blood Gas Values
3. Overnight Oximetry Studies
4. Flow Liters
5. Examples of conditions in which home oxygen use is not covered
6. Portable Oxygen System
7. Emergency or Standby Oxygen
8. Home Oxygen for COPD
9. Home Oxygen Use to Treat Cluster Headaches (CH)
DEFINITIONS
REFERENCES
REVISION HISTORY
COVERAGE
Coverage Statement: Home use of oxygen is covered when Medicare coverage criteria are met.
DME Face to Face Requirement: Effective July 1, 2013, Section 6407 of the Affordable Care Act
(ACA) established a face-to-face encounter requirement for certain items of DME (including home
oxygen). For DME Face to Face Requirement information, refer to the Coverage Summary of Durable
Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and
Medical Supplies Grid.
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Guidelines/Notes:
The following guidelines (Guidelines 1 -7) are based on the NCD for Home Use of Oxygen (240.2) and
the DME MAC LCDs for Oxygen and Oxygen Equipment (L33797). Compliance with these LCDs is
required where applicable. (Accessed January 18, 2017)
1.
Indications and Limitations of Coverage
Medicare coverage of home oxygen and oxygen equipment under the durable medical equipment
(DME) benefit is considered reasonable and necessary only for patients with significant
hypoxemia who meet the medical documentation, laboratory evidence, and health conditions
specified below.
2.
Medical Documentation, Laboratory Evidence and Covered Blood Gas Values
a. The treating physician’s prescription or other medical documentation must indicate that other
forms of treatment (e.g., medical and physical therapy directed at secretions, bronchospasm
and infection) have been tried, have not been sufficiently successful, and oxygen therapy is
still required. While there is no substitute for oxygen therapy, each patient must receive
optimum therapy before long-term home oxygen therapy is ordered.
b.
A physician’s certification of medical necessity for oxygen equipment must include the results
of specific testing before coverage can be determined.
Claims for oxygen must also be supported by medical documentation in the patient’s record.
Separate documentation is used with electronic billing. This documentation may be in the
form of a prescription written by the patient’s attending physician who has recently examined
the patient (normally within a month of the start of therapy) and must specify:



A diagnosis of the disease requiring home use of oxygen;
The oxygen flow rate; and
An estimate of the frequency, duration of use (e.g., 2 liters per minute, 10 minutes
per hour, 12 hours per day), and duration of need (e.g., 6 months or lifetime)
Note: A prescription for “Oxygen PRN” or “Oxygen as needed” does not meet this last
requirement. Neither provides any basis for determining if the amount of oxygen is
reasonable and necessary for the patient.
c.
Oxygen for home use and accompanying necessary accessories is recommended when ALL
of the following conditions are met:
1) The treating physician has determined that the patient has a severe lung disease or
hypoxia-related symptoms that might be expected to improve with oxygen therapy
2) The member’s blood gas study meets the criteria stated below
(See GROUP I, II, III criteria below)
3) The qualifying blood gas study was performed by a physician or by a qualified provider
or supplier of laboratory services
4) The qualifying blood gas study was obtained under the following conditions:
a. Inpatient hospital stay: The reported test must be the one obtained closest to, but no
earlier than 2 days prior to the hospital discharge date, or
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5)
d.
b. Non-Inpatient hospital stay: The reported test must be performed while the patient is
in a chronic stable state
Alternative treatment measures (as described in 1-A above) have been tried and found
or considered and deemed clinically ineffective
Covered Blood Gas Values
(Note: In this policy, the term blood gas study refers to either an oximetry test or an arterial
blood gas test)
Group I criteria include any of the following
1. Arterial PO2 at or below 55 mm Hg or arterial oxygen saturation at or below 88%, taken at
rest, breathing room air
2. Arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88%, for at
least 5 minutes taken during sleep for a patient who demonstrates an arterial PO2 at or
above 56 mm Hg or an arterial oxygen saturation at or above 89% while awake
3. A decrease in arterial PO2 more than 10 mm Hg or a decrease in arterial oxygen saturation
more than 5%, for at least 5 minutes taken during sleep with symptoms or signs reasonably
attributable to hypoxemia
4. Arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88%, taken
during exercise for a member who demonstrates a PO2 at or above 56 mm Hg or an arterial
oxygen saturation at or above 89% during the day while at rest. In this case, oxygen is
provided for during exercise if it is documented that the use of oxygen improves the
hypoxemia that was demonstrated during exercise when the beneficiary was breathing
room air.
Note: In cases 1-4 above, initial coverage is limited to 12 months or the physician specified
length of need, whichever is shorter.
Group II criteria include the following:
Members with arterial PO2 at 56-59 mm Hg or an arterial blood oxygen saturation of 89% at
rest (awake), during sleep for a continuous period of at least 5 minutes, or during exercise (as
described under Group I criteria), AND any of the following:
1. Dependent edema suggesting congestive heart failure (CHF)
2. Cor Pulmonale (pulmonary hypertension), determined by measurement of pulmonary
artery pressure, gated blood pool scan, echocardiogram, or "P" pulmonale on EKG (P
wave greater than 3 mm in standard leads II, III, or AVF)
3. Erythrocythemia with a hematocrit greater than 56%
Note: Initial coverage for patient meeting Group II criteria is limited to 3 months or the
physician specified length of need, whichever is shorter. (Refer to the Certification section for
information on recertification.)
Group III includes beneficiaries:
Patients with arterial PO2 levels at or above 60mm Hg or arterial blood oxygen saturations at
or above 90 %. For these patients there is a presumption of non-coverage which must be
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refuted.
3.
Overnight Oximetry Studies
Members may self-administer home based overnight oximetry tests under the direction of a
Medicare-enrolled Independent Diagnostic Testing Facility (IDTF). A DME supplier or another
shipping entity may deliver a pulse oximetry test unit and related technology, to a member’s home.
Home oximetry testing for determining home oxygen use is covered when the following criteria
are met:
a. The patient’s treating physician has contracted the independent diagnostic testing facility
(IDTF) to order the overnight pulse oximetry test before it is performed
b. The test is performed under the direction and/or instruction of a Medicare-approved IDTF.
Because it is patient who self-administers this test, the IDTF must provide clear written
instructions on the proper operation of test equipment and must include access to the IDTF in
order to address other concerns that might arise. The DME provider may not provide the
instructions, answer questions or participate in the test in any way.
c. Test must be sealed and tamper proof such that the test results cannot be accessed by anyone
other than the IDTF who is responsible for transmitting a test report to the treating physician.
Notes:
 DME providers may use technology to download the test to the IDTF. In no case may a
DME supplier access or manipulate test results in any form.
 IDTF must send the test results to the physician. The IDTF may send the test results to the
supplier if the supplier is currently providing or has an order to provide oxygen or other
respiratory services to the beneficiary or if the beneficiary has signed a release permitting
the supplier to receive the report.
 Oximetry results obtained through a similar process while the patient is awake, either at
rest or exercise, cannot be used to qualify a patient for home oxygen.
4.
Flow Liters
Liter flow greater > 4 LPM for home use is covered when Group I or Group II criteria for oxygen
are met and the blood gas study is performed while the patient is on 4 LPM.
5.
Home oxygen usage is not covered for the following:
a. Angina pectoris in the absence of hypoxemia
b. Breathlessness or dyspnea without cor pulmonale or evidence of hypoxemia
c. Severe peripheral vascular disease resulting in clinically evident desaturation in one or more
extremities but in the absence of systemic hypoxia
d. Terminal illnesses that do not affect the respiratory system
6.
Portable Oxygen System
Portable Oxygen system may be purchased for chronic use when patient is mobile within the home
and the qualified blood gas study was performed while rest (awake) or during exercise. If patient
meets the above requirement, the portable oxygen system is usually paid for separately in addition
to the stationary system.
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Notes:
o If a patient qualifies for additional payment for greater than 4 LPM of oxygen and also meets
the requirements for portable oxygen, payment will be made for either the stationary system of
oxygen (at higher allowance) or the portable system (at the standard fee schedule allowance
for portable system), but not both.
o When a portable system is added to a stationary system or vise versa a need for blood gas
study is not required.
o If a portable oxygen system is covered, the supplier must provide whatever quantity of oxygen
the beneficiary uses; Medicare’s reimbursement is the same, regardless of the quantity of
oxygen dispensed.
7.
Emergency or Standby Oxygen
Emergency or stand-by oxygen tanks, concentrators and other oxygen systems for patients who are
not regularly using oxygen are not covered and will be denied as not reasonable and necessary
since they are precautionary and not therapeutic in nature.
8.
Home Oxygen for COPD
The home use of oxygen is covered for those members with arterial oxygen partial pressure
measurements from 56 to 65 mmHg or oxygen saturation at or above 89% who are enrolled
subjects in clinical trials approved by CMS and sponsored by the National Heart, Lung, and Blood
Institute [(NHLBI); CMS, 2006)] The additional Group II criteria do not apply to these patients.
See the NCD for Home Use of Oxygen in Approved Clinical Trials (240.2.1). (Accessed January
18, 2017)
The list of Medicare approved clinical trials is available at
http://www.cms.gov/Medicare/Coverage/Coverage-with-Evidence-Development/Home-Oxygenfor-COPD.html. (Accessed January 18, 2017)
For payment rules for NCDs requiring CED, see the Coverage Summary for Experimental
Procedures and Items, Investigational Devices and Clinical Trials
9.
Home Oxygen Use to Treat Cluster Headaches (CH)
Effective for claims with dates of services on or after January 4, 2011, the home use of oxygen to
treat CH is covered by Medicare only for beneficiaries with CH participating in an approved
prospective clinical study comparing normobaric 100% oxygen (NBOT) with at least one clinically
appropriate comparator for the treatment of CH.
See the NCD for Home Oxygen Use to Treat Cluster Headache (CH) (240.2.2) for specific
coverage information. (Accessed January 18, 2017)
The list of Medicare approved clinical trials is available at
http://www.cms.gov/Medicare/Coverage/Coverage-with-Evidence-Development/Home-Oxygenfor-Cluster-Headache.html. (Accessed January 18, 2017)
For payment rules for NCDs requiring CED, see the Coverage Summary for Experimental
Procedures and Items, Investigational Devices and Clinical Trials.
II.
DEFINITIONS
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III.
REFERENCES
See above
IV.
REVISION HISTORY
02/14/2017
Annual review with the following updates:
Guideline 1 - Moved the following language: “The following guidelines (Guidelines 1 7) are based on the NCD for Home Use of Oxygen (240.2) and the DME MAC LCDs for
Oxygen and Oxygen Equipment (L33797). Compliance with these LCDs is required
where applicable.” from the end of guideline 1 to before Guideline 1.
Guideline 5 (Home oxygen usage is not covered for the following) – Added “or
dyspnea” to guideline 5.b. to reflect language from DME MAC LCD for Oxygen and
Oxygen Equipment (L33797)
02/16/2016
Annual review with the following updates:
 Guideline 2.d (Covered Blood Gas Values; Group I Criteria) -Moved the
following language from “Notes” section to item #4:
“In this case, oxygen is provided for during exercise if it is documented that the use
of oxygen improves the hypoxemia that was demonstrated during exercise when the
beneficiary was breathing room air.”
 Guideline 2.d (Covered Blood Gas Values; Group II Criteria)
o Added the following language to item #2: “determined by measurement of
pulmonary artery pressure, gated blood pool scan, echocardiogram, or "P"
pulmonale on EKG (P wave greater than 3 mm in standard leads II, III, or
AVF “
o Removed the following under “Notes” section: “of the physician specified
length of need, whichever is shorter.”
 Guideline 5 (Home Oxygen) - Deleted the following language: “Patients with
arterial PO2 levels at or above 60mm Hg or arterial blood oxygen saturations at or
above 90 %, except if there is substantial documentation by the physician of need”
 Guideline 6 (Portable Oxygen System) - Added the following language under
“Notes” section: “If a portable oxygen system is covered, the supplier must provide
whatever quantity of oxygen the beneficiary uses; Medicare’s reimbursement is the
same, regardless of the quantity of oxygen dispensed.”
04/21/2015
Guideline #8 (Home Oxygen for COPD)
 Changed title from “Medicare Clinical Trial Coverage” to “Home Oxygen for
COPD”
 Added reference link to the list of Medicare approved clinical trials.
 Updated payment info; added reference link to the Coverage Summary for
Experimental Procedures and Items, Investigational Devices and Clinical Trials for
payment rules for NCDs requiring CED.
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Guideline # 9 (Home Oxygen Use to Treat Cluster Headaches)
 Added reference link to the list of Medicare approved clinical trials.
 Updated payment info; added reference link to the Coverage Summary for
Experimental Procedures and Items, Investigational Devices and Clinical Trials for
payment rules for NCDs requiring CED.
03/24/2015
10/21/2014
Annual review with following updates:
 Guideline # 3 (Overnight Oximetry Studies)
- Updated title from” Home Sleep Overnight Oximetry Studies/Testing” to
“Overnight Oximetry Studies”
- Removed reference to “Test results obtained under these circumstances will be
accepted for the purpose of qualifying for home oxygen therapy. See the DME
MAC Local Articles for Overnight Oximetry Testing – Policy Clarification
(A36044; A47120; A35433)”. These articles are retired.
 Definitions:
- Oxygen Concentrator- deleted not in body of CS.
- Oximetry Device – deleted not in body of CS.
Removed detailed DME Face-to-Face Requirement information and replaced with a
reference link to the DME, Prosthetics, Corrective Appliances/Orthotic and Medical
Supplies Grid.
02/18/2014
Annual review; no updates
08/20/2013
Added a note pertaining to the DME Face-to-Face Requirement in accordance with
Section 6407 of the Affordable Care Act as defined in the 42 CFR 410.38(g)
02/19/2013
Annual review; no updates
02/27/2012
Annual review; updated to include additional benefit coverage clarification to the
following:
o Guidelines #2.d Covered Blood Gas Values;
o Guidelines #3-Home Sleep Oximetry Studies/Testing; and
o Guidelines #7-Emergency or Standby Oxygen
06/30/2011
Annual review; no updates
02/21/2011
Updated to include
Guidelines #3 Home Oxygen Use to Treat Cluster Headaches based on the new NCD for
Home Oxygen Use to Treat Cluster Headaches (CH) (240.2.2)
12/21/2010
Corrected/updated the link to the NCD for Home Use of Oxygen (240.2); could not open
NCD link
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